Retained plastic foreign body in the orbit after blunt trauma: A case report

Abstract

Intraorbital foreign bodies (IOFBs) are rare but potentially vision-threatening complications of orbital trauma, often presenting with subtle clinical signs despite significant underlying injury. We report the case of a 22-year-old male who sustained periorbital trauma after facial impact with a high-velocity plastic projectile. Clinical examination revealed a penetrating wound at the medial canthus of the left orbit, with preserved visual acuity and normal intraocular pressure. Computed tomography identified a radiopaque foreign body embedded in the inferomedial orbital floor. Surgical removal via a transconjunctival approach led to complete extraction of a spherical plastic object, with uneventful recovery and no postoperative complications. This case underscores the diagnostic challenges posed by nonmetallic IOFBs and the critical role of CT imaging in orbital trauma. Management strategies depend on the nature, size, and location of the foreign body, as well as associated complications such as globe perforation, infection, or oculomotor dysfunction. Prompt surgical intervention is essential to prevent long-term ocular and functional sequelae.

Introduction

Intraorbital foreign bodies (IOFBs) are objects that penetrate the orbital cavity without damaging the globe itself. While relatively rare, these injuries can lead to significant complications, including infections, functional impairments of the extraocular muscles, optic nerve compression, and, in severe cases, loss of vision . IOFBs are often associated with high-energy orbital-facial trauma, where the penetrating object may reach sensitive areas of the orbit without directly affecting the ocular globe. These injuries account for approximately 16% of orbital trauma cases, highlighting their clinical importance [1].

The diagnosis of IOFBs requires a high index of suspicion, coupled with advanced imaging techniques. Due to the diverse nature of the materials, shapes, and locations of foreign bodies, IOFBs can sometimes be challenging to detect. Nonmetallic objects, such as plastic, pose particular challenges due to their low radiopacity, which can result in misinterpretation of imaging findings. Therefore, computed tomography (CT) is considered the imaging modality of choice for precise localization of the foreign body and assessment of adjacent orbital structures [2].

The management of IOFBs is a delicate issue, requiring careful evaluation of the risks associated with surgery. Treatment depends on the location of the foreign body and its relationship with vital structures such as the extraocular muscles and optic nerve. In most cases, surgical extraction is recommended, especially when symptoms are acute or there is a threat to vision. However, extraction should be performed cautiously to avoid additional complications, such as infection, hemorrhage, or nerve damage. The therapeutic approach may involve minimally invasive or more complex procedures, depending on the accessibility of the foreign body and the associated anatomical risks.

Thus, while IOFBs remain a rare pathology, their management demands a rigorous approach, combining early diagnosis, appropriate imaging techniques, and surgical intervention to preserve ocular function and prevent long-term complications [3].

Case presentation

We report the case of a 22-year-old male patient who presented to the Department of Otorhinolaryngology and Maxillofacial Surgery with complaints of progressive redness and blurred vision in the left eye, following a facial trauma. The patient had sustained a penetrating injury to the internal canthus of the left eye, which had been initially managed at a primary healthcare center with wound suturing.

Upon admission, clinical examination revealed a sutured laceration involving the upper eyelid and medial canthal region, extending to the nasal bridge (Fig. 1). The patient presented with conjunctival chemosis, preserved visual acuity, and normal intraocular pressure. Extraocular motility testing showed limitation in both abduction and adduction of the left eye, with diplopia observed in upward and lateral gaze positions. Pupils were round, equal, and reactive bilaterally, with no relative afferent pupillary defect.

Fig. 1.

The figure depicts a lacerated wound on the left upper eyelid extending anteriorly towards the nose, which was sutured at the primary care facility.

A facial CT scan was performed to assess the extent of orbital trauma. Axial (Fig. 2), sagittal (Fig. 3), coronal (Fig. 4), and 3D reconstructions (Fig. 5) revealed a spherical, hyperdense foreign body lodged in the inferomedial portion of the left orbit. The object did not compromise the globe or optic nerve. Associated findings included fractures of the frontal sinus anterior wall, the medial orbital wall, the frontal process of the maxilla, and a displaced nasal bone fracture. No damage to the cribriform plate or intracranial structures was observed.

Fig. 2.

This figure showed an axial CT scan revealing a rounded foreign body located between the medial orbital wall and the ethmoid air cells.

Fig. 3.

This figure showed a sagittal CT scan with no evidence of a fracture at the base of the skull.

Fig. 4.

This figure showed a frontal CT scan demonstrating the plastic foreign body located medially to the medial oculomotor muscle.

Fig. 5.

This figure showed a 3D CT scan reconstruction illustrating an intraorbital foreign body, with associated fractures of the nasal bone and the frontal process of the left maxilla.

The patient underwent surgical exploration under general anesthesia. The previous wound was excised, and a medial orbitotomy was performed through the existing laceration. Intraoperatively, a soft, plastic projectile approximately 1 cm in diameter was identified penetrating the medial orbital wall and extending into the anterior ethmoid sinus, with associated orbital floor disruption (Fig. 6). The object was carefully extracted without complication, followed by copious irrigation and layered closure of the wound (Fig. 7).

Fig. 6.

This figure showed an intraoperative view of the plastic foreign body and its successful removal.

Fig. 7.

This figure showed a rounded plastic foreign body approximately 1 cm in diameter.

Postoperative recovery was uneventful. Follow-up at 1 month showed complete resolution of diplopia and restoration of full extraocular motility. The patient maintained normal visual acuity, and no signs of optic nerve damage or secondary infection were noted.

Discussion

Penetrating orbital trauma with intraorbital foreign bodies (IOFBs) represents a rare but clinically significant entity, accounting for approximately 2.9% of all orbital injuries. Although uncommon, IOFBs can lead to significant morbidity, including permanent visual impairment, chronic inflammation, and life-threatening complications. These injuries are often associated with high-velocity trauma, such as occupational accidents, ballistic injuries (e.g., gunshot wounds), assaults, and motor vehicle collisions. While the orbital bony walls and surrounding soft tissues provide a certain degree of protection against cranial penetration, this anatomical defense may be insufficient when high-energy or sharp projectiles are involved. The underlying risk for IOFBs is heightened by the increased use of machinery and firearms in both civilian and military settings. Prompt recognition and management of IOFBs are essential to prevent complications such as blindness, orbital infection, or intracranial extension, which can significantly affect patient outcomes. Studies suggest that the prevalence of IOFBs correlates with environmental factors, including the prevalence of industrial hazards and gun violence in certain geographic regions [4].

The mechanisms by which IOFBs cause injury are multifactorial and are influenced by factors such as the foreign body's size, shape, velocity, and composition. The speed and impact of the object are critical in determining the extent of injury and the depth of penetration into the orbital space. The anatomical characteristics of the orbit, including its bony walls and soft tissue padding, offer a certain level of resistance to foreign body penetration. However, when high-velocity or sharp objects are involved, this defense may be breached, resulting in deeper orbital penetration or even intracranial involvement. Foreign bodies that penetrate the orbit may also disrupt the anatomical relationships between the globe, optic nerve, and extraocular muscles, exacerbating the potential for visual impairment and functional deficits [5].

Foreign bodies are typically classified based on their chemical composition, with 3 major categories: metallic, inorganic nonmetallic, and organic. Metallic foreign bodies, such as steel and copper, are often the result of industrial accidents or gunshot injuries. Inorganic materials like glass or plastic, while generally inert, may still lead to local inflammation or infection, particularly if left untreated. Organic materials, including wood or plant matter, are highly reactive and often provoke granulomatous inflammatory responses, which significantly increase the risk of secondary infection and complications. The degree of inflammation depends on the material's ability to incite a host immune response and its persistence within the orbital space.

The clinical presentation of IOFBs is highly variable, ranging from asymptomatic findings to severe vision-threatening emergencies. Symptoms are often nonspecific and may be masked by concurrent facial trauma. Common presenting signs include periorbital pain, swelling, eyelid lacerations, and restriction of ocular motility. Proptosis may result from direct trauma to the orbital fat and soft tissues, and diplopia can occur due to extraocular muscle entrapment or mechanical obstruction by the foreign body. The involvement of neurovascular structures, such as the optic nerve, cavernous sinus, or paranasal sinuses, can lead to more severe outcomes. Vision disturbances may arise due to direct trauma to the globe, optic nerve compression, or ischemic injury. If the foreign body is located posteriorly or deep within the orbit, the clinical signs may be subtle, and the diagnosis can be easily overlooked. Delayed presentation may also occur if small entry wounds or eyelid lacerations are not readily identified during the initial evaluation [6].

The recognition of deeper orbital involvement is critical, as it may result in afferent pupillary defects, cranial nerve palsies, or signs of intracranial penetration. Persistent inflammation or abnormal ocular motility, particularly if symptoms worsen over time, should raise suspicion for the presence of an IOFB, especially in the context of a history of recent trauma. The presence of chemosis, eyelid erythema, or palpable orbital mass should also prompt further investigation for potential IOFBs or associated orbital fractures.

A comprehensive and accurate paraclinical evaluation is crucial for the early detection, localization, and characterization of IOFBs. Imaging plays a pivotal role in identifying the foreign body, determining its size and composition, and assessing the extent of associated orbital and neurovascular damage. Computed tomography (CT) is considered the gold standard for detecting radiopaque foreign bodies and is particularly effective in evaluating metallic and plastic IOFBs. CT offers high spatial resolution and multiplanar reconstruction, allowing for detailed visualization of orbital fractures, hemorrhages, and soft tissue damage [4]. It is particularly valuable for assessing fractures of the orbital floor or roof, as well as the presence of any intracranial extension or involvement of the paranasal sinuses [7].

In orbital trauma, CT imaging is not only essential for identifying the presence of a foreign body but also provides crucial information that directly influences clinical decision-making. According to Courtier et al., characteristic CT patterns can help differentiate between various types of foreign materials and guide the surgical approach, especially in cases where the clinical signs are subtle. For example, the presence of air tracking, retrobulbar hemorrhage, or disruption of orbital walls may indicate the need for urgent intervention [8].

Plain radiography may be useful for identifying metallic foreign bodies but is limited in detecting radiolucent materials such as organic objects (e.g., wood or plant matter) . Ultrasonography can help evaluate intraocular involvement and identify the presence of a foreign body in the eye or orbit. However, its operator dependence, limitations in acute trauma cases, and contraindications in suspected globe rupture significantly reduce its clinical utility.

Magnetic resonance imaging (MRI) is not typically recommended for patients with suspected metallic IOFBs due to the risk of displacement or injury caused by the magnetic field. However, MRI is the preferred modality for detecting organic foreign bodies, especially when CT findings are inconclusive. Organic materials such as wood or plant matter may be radiolucent on CT but can appear well-defined on MRI due to differences in tissue characteristics. Additionally, MRI is beneficial for assessing soft tissue involvement and evaluating the extent of inflammation, especially in the posterior orbital region [9].

Vascular imaging, such as CT or MR angiography, may be indicated if there is suspicion of cavernous sinus involvement or intracranial penetration. These studies help evaluate potential vascular damage and inform decisions regarding surgical management.

The management approach for IOFBs should be tailored to the individual patient, taking into consideration factors such as the foreign body’s location, composition, size, and any associated complications. Inorganic metallic and glass foreign bodies, when asymptomatic and located deep in the posterior orbit, may be left in situ to avoid unnecessary surgical risks. In these cases, careful monitoring is essential to detect any delayed complications, such as infection or secondary inflammation [10].

Organic foreign bodies, regardless of location, should be removed promptly due to their propensity to cause infection and granulomatous inflammation. Similarly, plastic foreign bodies, particularly those near the paranasal sinuses or orbital sinuses, should be surgically removed to prevent the development of abscesses, sinusitis, or fistulas.

Decision-making regarding the timing and modality of intervention is closely linked to the imaging findings. CT allows the surgeon to evaluate proximity to vital structures such as the optic nerve, extraocular muscles, and orbital apex—information that is crucial for planning a safe and effective surgical approach.

Surgical removal of symptomatic foreign bodies is generally indicated in cases with ocular motility disturbances, compression of the optic nerve, or persistent inflammation. The surgical approach is typically dictated by the location of the foreign body and surrounding anatomical structures. Anterior foreign bodies may be accessed through a transcutaneous or transconjunctival approach, while deep or posterior foreign bodies may require a more specialized endoscopic or transscleral approach [11].

Intraoperative considerations include careful preservation of globe integrity, optic nerve function, and extraocular muscle mobility. Postoperative management should include the use of broad-spectrum antibiotics, particularly in cases involving organic or contaminated foreign bodies, and close monitoring for signs of infection or delayed complications. Corticosteroids may be considered to reduce inflammatory responses and minimize long-term motility restrictions [12].

The visual and functional prognosis for patients with IOFBs largely depends on the severity of the initial trauma, the timing of diagnosis, and the adequacy of surgical intervention. Early diagnosis and prompt removal of the foreign body typically result in favorable outcomes, particularly in the absence of optic nerve damage or globe rupture. Postoperative improvement in ocular motility and resolution of diplopia are commonly observed, especially in cases where the foreign body was removed before significant muscle or nerve damage occurred [13].

In contrast, delayed diagnosis and treatment can result in chronic inflammation, vision loss, restrictive strabismus, or orbital deformities. Retained foreign bodies, particularly organic or plastic materials, may lead to long-term complications, including persistent infection, orbital abscesses, or even intracranial extension in severe cases. Long-term follow-up is critical to monitor for late complications such as fibrosis, restrictive motility, or chronic sinusitis. Prevention, through the use of protective eyewear in high-risk settings and early imaging in suspected cases of orbital trauma, remains a cornerstone in reducing the incidence and severity of IOFBs [14].

Conclusion

Intraorbital foreign bodies (IOFBs) represent a rare yet clinically significant cause of orbital trauma, with potential for severe visual and functional impairment. Early diagnosis, precise imaging, and tailored surgical management are critical in optimizing outcomes and preventing complications such as infection, chronic inflammation, and neurovascular damage. The prognosis largely depends on the composition of the foreign body, the timing of intervention, and the extent of initial injury. Prompt removal of organic and plastic foreign bodies, along with careful monitoring of metallic and glass fragments, is essential to minimize long-term sequelae. Preventive measures, including occupational safety and timely imaging in high-risk trauma, remain key strategies in reducing the morbidity associated with IOFBs.

Patient consent

The patient gave their informed consent to the publication of this case report.